Original Article Plastic and Aesthetic Research

Heel pad avulsion injury: an approach with hyperbaric oxygen therapy

Pradeoth Korambayil Mukundan, Prashanth Varkey Ambookan Department of Plastic Surgery and Burns, Jubilee Institute of Surgery for Hand, Aesthetic and Microsurgery, Jubilee Mission Medical College and Research Institute, Thrissur 680007, Kerala, India. Address for correspondence: Dr. Pradeoth Korambayil Mukundan, Flat No. 102, Nandana, Haritha Gardens, Vadookara, Thrissur 680007, Kerala, India. E‑mail: [email protected]

ABSTRACT Aim: Crush injuries of the foot are often associated with partial or complete degloving of the heel pad. The purpose of this study is to present an algorithm for the management of various types of heel pad avulsion injuries, including hyperbaric oxygen (HBO) therapy in the treatment regimen. Methods: We present a prospective study of 27 patients with various types of heel pad avulsion managed in our institution from December 2012 to June 2013. Heel pad avulsion injuries were classified according to the angiosomal pattern. Partial or complete avulsions were classified and treated accordingly. HBO therapy was administered postoperatively. The postoperative period, hospital course, and follow‑up were documented in patients with heel pad avulsion injuries. Results: Of 27 patients, 20 cases presented with partial avulsion and 7 cases were complete avulsion. Of 20 cases of partial avulsion, one of the flaps was anchored with K‑wire. Nineteen cases of partial heel pad avulsion were managed by suturing. Eight patients out of 20 required skin grafting as a secondary procedure at a later date. Out of 7 cases of complete avulsion, one was managed by full‑thickness skin grafting, one case by reverse sural artery flap coverage, and four cases were managed by free tissue transfer. No flap revisions were required, and no complications were experienced for the transferred flaps.Conclusion: HBO therapy may be a useful adjunct in the treatment of heel pad avulsion injuries. Key words: Angiosome, heel pad avulsion, hyperbaric oxygen therapy, soft tissue reconstruction

INTRODUCTION to be complete and may require removal of the avascular tissue and reconstruction with local or distant flaps. Foot trauma is a significant cause of morbidity among the Providing sensate and glabrous skin may not be possible working age population. Crush injuries to the foot are in patients with extensive injuries.[2] There are clinical often associated with avulsion injuries of the heel pad. situations in which the avulsed heel pad structure may be Heel pad avulsion injuries are always a challenge for the viable, requiring debridement and anchoring of the heel plastic surgeons, as the reconstructed tissue, even though pad flap in position. In cases of partial avulsion, the heel sensate, may not match the unique and complex nature pad is, usually, debrided, reattached in position by sutures of the native fat pad structure. Heel pad avulsion injuries or K‑wire fixation, and further surgical interventions are [1] may be partial or complete. When the avulsed heel pad postponed until there has been a demarcation of the tissue is avascular or clinically nonviable, avulsion is said nonviable tissue.[1] As the heel pad tissue is irreplaceable, there is a need for alternative methods of preserving the Access this article online marginal tissue as well as preventing ischemia and hypoxic Quick Response Code: Website: advancement of the injured tissue. In this prospective www.parjournal.net study, various treatment modalities including hyperbaric oxygen (HBO) therapy, primary closure, full thickness skin grafting/split thickness skin grafting (FTSG/STSG), and local DOI: 10.4103/2347-9264.153200 or distant flap coverage were utilized to preserve and reconstruct the valuable heel pad tissue.

56 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 METHODS heel pad avulsion were managed by primary closure. Eight patients out of 20 required skin grafting as a secondary Twenty‑seven patients with heel pad avulsion (isolated/ procedure at a later date. Out of 7 cases of complete combined) were treated over a period of avulsion, one was managed by full‑thickness skin 7 months (December 2012 to June 2013). The avulsed heel grafting, one case by reverse sural artery flap coverage, pad flaps were classified on the basis of the angiosomal and four cases were managed by free tissue transfer. concept. Heel pad flaps based distally were classified as Among the free tissue transfer, two were latissimus dorsi tissue receiving its vascular supply from the medial plantar muscle flaps, one was a gracilis muscle flap, and one and lateral plantar artery angiosomal territories. Flaps was an anterolateral thigh flap [Table 1]. There were no based distally and medially were considered to receive complications following flap transfer and graft take was their vascular supply from the medial and lateral plantar adequate. The patients in our series did not experience arteries and the calcaneal branch of the posterior tibial the common side‑effects of HBO therapy such aural or artery. Flaps based distally and laterally were considered pulmonary barotrauma or transient reversible myopia to have a vascular supply based on the medial and lateral during the treatment sessions. No complications were plantar arteries and the calcaneal branch of the peroneal noted during the follow‑up period. artery. Those flaps with proximal continuity were classified Case 1 as having their blood supply from perforators of either A 43‑year‑old female was admitted with a crush injury the posterior tibial or peroneal vessels. to the right leg and foot region following a crush injury Following initial assessment and resuscitation of by a heavy vehicle [Figure 1a]. The patient presented the patient according to the ATLS protocols, acutely with soft tissue loss over the anterior aspect of the presenting heel pad avulsion injuries were assessed for leg and dorsum of the foot. The heel pad was avulsed the extent of degloving, skeletal injury, associated soft from the calcaneum but was continuous to the proximal tissue loss, vascularity to the heel pad flap, and flap and the distal aspect by the skin and subcutaneous avulsion patterns. Patients were informed about the line of tissue [Figure 1b]. Stabilization of the ankle and heel management, possible treatment modalities, and the need pad was performed with an external fixator following for additional surgery procedures pertaining the pattern wound debridement. Soft tissue coverage of the anterior aspect of the leg and dorsum of the foot was provided of injuries. Patients were started on empirical antibiotic by a latissimus dorsi free flap and split‑thickness skin therapy, including a third‑generation cephalosporin and grafting [Figure 1c and d]. The vessels of the latissimus anaerobic coverage. Adequate analgesia was assured. dorsi flap were anastomosed end‑to‑side to the Thorough wound debridement and fixation of the posterior tibial vessels as the anterior tibial vessels were fractures was performed. In cases of partial avulsion avulsed up to the level of middle third of the leg. HBO requiring the anchorage, HBO therapy was initiated during therapy was administered in 6 sessions postoperatively. the immediate postoperative period. Six sessions of HBO Following demarcation of the avascular tissue over the therapy, each session lasting 1 h and continued for 6 days, medial part of the leg and proximal heel pad, nonviable was administered to the patients postoperatively. In cases tissue was debrided. Because there was adequate soft of complete avulsion, the nonviable tissues were debrided, tissue padding over the calcaneum, skin grafting was and depending upon the patient’s condition, soft tissue performed [Figure 1e-g]. Six sessions of HBO therapy reconstruction was performed as early as possible. were administered following skin grafting. Postoperatively, 6 HBO therapy sessions were administered for all patients. Immobilization of the limb was done in all Case 2 cases. Outcomes following each type of management and An 18‑year‑old male was admitted with a crush injury of secondary procedures performed were noted. the right leg and foot with heel pad avulsion. Skin and subcutaneous tissue were connected in the proximal and distal aspects [Figure 2a]. The heel pad was anchored with K‑wires by the orthopedic department, and the RESULTS patient was then referred to plastic surgery for further management [Figure 2b]. HBO therapy was administered The mode of injury for all patients was road traffic for six sessions. Following demarcation of the nonviable accident. Out of 27 patients, there were 5 female (18.1%) tissue, the avascular tissue was debrided [Figure 2c and d]. and 22 male patients (81.9%). Mean age was 34.18 years (range: 5‑53 years). For 12 patients the avulsed flap was Most of the foot pad tissue was found to be preserved, based distally, in 7 patients the flap was based distally and skin grafting was sufficient for coverage of the soft and laterally, in 5 patients the flap was based distally and tissue defect following debridement [Figure 2e and f]. Six medially, in 2 patients the flap had proximal and distal additional sessions of HBO therapy were administered connections with disruption in the medial and lateral following skin grafting. aspects and in 1 patient the flap was continuous only in the lateral and medial aspects. Out of 20 cases of partial Case 3 avulsion, one of the flaps was anchored with K‑wires by A 52‑year‑old male was admitted with heel pad avulsion the orthopedic department, and then referred to plastic based distally [Figure 3a]. Primary closure was performed surgery for soft tissue coverage. Nineteen cases of partial following debridement [Figure 3b and c]. HBO therapy was

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 57 administered for 6 sessions. The wound healed without commonly associated with degloving of the heel pad.[1] any additional intervention [Figure 3d]. The heel pad flaps are typically elevated in a posterior to anterior direction. Crush injuries may disrupt the heel DISCUSSION pad in various flap patterns, which are medially based, laterally based, medially and anteriorly based, or laterally Crush injuries to the foot are a significant cause of and anteriorly based. In some cases, the soft tissues in the morbidity among the working age population and are medial, posterior and lateral areas are disrupted, leaving

a b c d

e f g Figure 1: (a) Crush injury to the right leg and foot region; (b) soft tissue loss anterior aspect of leg and dorsum of foot with heel pad avulsed from the calcaneum with continuity to the proximal and the distal part; (c) soft tissue coverage of leg and dorsum of foot with latissimus dorsi free tissue transfer; (d) free muscle tissue covered with split thickness skin graft; (e) status of heel region following debridement and hyperbaric oxygen therapy after 3 weeks of injury; (f) postoperative picture following skin grafting over heel pad region; (g) late postoperative picture

Table 1: The patients treated for heel pad avulsion injury No. Age (years)/ Mode of Base of Primary management Secondary gender injury vascularity following debridement procedure 1 32/male RTA Distal Primary suturing 2 23/male RTA Distal Primary suturing 3 24/female RTA Distal Primary suturing SSG 4 42/male RTA Distal Primary suturing SSG 5 53/male RTA Distal Latissimudorsi flap 6 34/female RTA Distal Latissimus dorsi flap 7 42/male RTA Distal and lateral Primary suturing 8 27/male RTA Distal and medial Primary suturing 9 34/male RTA Distal Gracilis flap 10 5/male RTA Distal FTSG 11 52/female RTA Distal Primary suturing 12 25/male RTA Distal and lateral Primary suturing SSG 13 27/male RTA Distal and lateral Primary suturing 14 21/male RTA Distal and lateral Primary suturing SSG 15 28/male RTA Distal and lateral Primary suturing 16 43/male RTA Distal and lateral Primary suturing 17 42/male RTA Lateral and medial Primary suturing SSG 18 37/male RTA Distal and lateral Primary suturing 19 43/female RTA Proximal and distal Latissimus dorsi flap SSG 20 35/male RTA Distal and medial Primary suturing 21 39/male RTA Distal and medial Primary suturing 22 42/male RTA Distal and medial Primary suturing 23 45/male RTA Distal and medial Primary suturing SSG 24 21/female RTA Distal Primary suturing SSG 25 18/male RTA Proximal and distal Anchorage with K‑wire SSG 26 47/male RTA Distal Reverse sural flap 27 42/male RTA Distal Anterolateral thigh flap RTA: Road traffic accident, FTSG: Full thickness skin grafting, SSG: Split thickness skin grafting

58 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 a b c

d e f Figure 2: (a) Crush injury right leg and foot with heel pad avulsed skin and subcutaneous tissue connectivity in the proximal and distal part; (b) X-ray lateral view right foot showing K-wires used for stabilization of avulsed heel pad; (c) appearance of foot 3 weeks following debridement and hyperbaric oxygen treatment session; (d) plantar view of foot following 3 weeks; (e) medial view of the foot following skin grafting; (f) plantar view of the foot following skin grafting

a b

c d

Figure 3: (a) Heel pad avulsion based distally-medial view of left foot Figure 4: Diagram illustrating heel pad tissue degloved as a bucket foot; (b) wound debridement and primary suturing after placing a handle type over the calcaneal bone with continuity proximally and suction drain; (c) picture presenting the wound status during immediate distally with disruption of soft tissue medial and lateral aspect postoperative period; (d) late postoperative picture only a soft tissue bridge anteriorly. In some instances, the management of such complicated injuries [Figure 5]. the heel pad tissue is degloved in a “bucket handle” Out of 6 angiosomes of the foot and ankle, 3 angiosomes configuration over the calcaneal bone, with continuity are supplied by the posterior tibial artery, 2 angiosomes proximally and distally and disruption of the soft tissue are supplied by the peroneal artery, and 1 angiosome is in the medial and lateral aspects [Figure 4]. The heel pad supplied by the anterior tibial artery.[4] The calcaneal branch tissue, with its unique architecture, demands preservation of the posterior tibial artery supplies the medial aspect of in cases of any possible vascular supply. Premature efforts the ankle and the plantar aspect of the heel pad region. The to remove doubtful tissue may result in loss of valuable medial plantar branch of the posterior tibial artery feeds sensate heel pad tissue, which might have been preserved the medial aspect of the plantar instep. The lateral plantar by delayed intervention. However, a delayed intervention branch of the posterior tibial artery feeds the lateral aspect may also result in decreased survival rates of local or of the forefoot, the plantar aspect of the midfoot, and the distant tissue transfer secondary to tissue edema and an plantar aspect of the forefoot. The calcaneal branch of the increase in inflammatory factors. Since the zone of soft peroneal artery supplies the lateral aspect of the heel pad tissue compromise may extend beyond the zone of injury region.[5] Taylor et al.[4] found that these angiosomes are of the foot, reconstruction of heel pad with local or distant interconnected by either reduced caliber choke vessels soft tissue reconstruction can be challenging. In addition, or by anastomotic arteries. The principle of utilizing efforts to replace the heel pad with vascularized or HBO therapy for ulcers with vascular insufficiency and in regional flaps may be limited by decreased fine sensation, radiation‑induced wounds can be applied to the salvage of [3] bulky soft tissues, and alteration in gait function. vital heel pad tissue. HBO therapy creates an increase in The vascular anatomy of the leg and foot by means of the dissolved oxygen in the plasma where there is increased angiosomal concept provides us with a better approach for partial pressure of arterial oxygen. Oxygen delivery through

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 59 tissue necrosis, reduce edema, control infection, support healing, and prevent reperfusion injury.[9] At the authors’ institution, a strategy has been developed to overcome these difficulties and to successfully manage these patients with a combined approach that maximizes tissue perfusion and oxygenation, allowing for surgical correction of such injuries. The current treatment algorithm [Figure 6] begins with surgical debridement and initiation of HBO therapy in the immediate postoperative period. HBO provides supersaturation of the plasma with oxygen, allowing a several‑fold increase in the oxygen diffusion gradient. Combination of the modalities allows preservation of marginal tissue, prevention of advancing ischemia and hypoxia and maximum preservation of heel pad tissue. This approach has been used in the current Figure 5: Angiosomal pattern of the heel pad and plantar foot region series of 27 patients, achieving maximal preservation of the heel pad with a return to ambulation. the plasma is increased through hemoglobin‑bound oxygen, facilitating oxygenation of the deprived tissue, Out of 27 patients, the avulsed flap was distally‑based in stimulating angiogenesis, fibroblast proliferation, leukocyte 12 patients, distally and laterally based in 7 patients and oxidative killing, antibiotic synergy, toxin inhibition and distally and medially based in 5 patients. In 2 patients the vasoconstriction. Vasoconstriction significantly reduces flap had proximal and distal connections with disruption tissue edema without hindering oxygenation. Decreasing in the medial and lateral aspects, and in 1 patient the flap edema is desirable in complicated plastic surgical wounds to was continuous in only the lateral and medial aspects. In relieve pressure on the surrounding vessels and structures. all cases, initial wound debridement was carried out and Oxygen delivery also leads to mature collagen formation HBO therapy sessions were started. If flap coverage was and stimulates angiogenesis.[6] Ulkür et al.[7] illustrated the required, surgery was scheduled as soon as the patient usefulness of HBO treatment during the delay period of was stable. HBO therapy was withheld on the day of the flap which can both decrease the time period needed surgery and recommenced on postoperative day one. When for the delay procedure and increased the effect of the flap skin grafting was performed at a later date, surgery was delay. The current study illustrates the utility of hyperbaric followed by six sessions of HBO therapy. Out of 20 cases therapy in the treatment of heel pad avulsion injuries. of partial avulsion, one flap was anchored with a K‑wire Most heel pad avulsion injuries with partial continuity act from the orthopedic department, and then referred to similar to a delayed flap. Hence, considering the valuable plastic surgery for soft tissue management. Nineteen cases heel pad tissue and the need for its preservation at any of partial heel pad avulsion were closed primarily. Eight cost, management should include a modality which can patients out of 20 required skin grafting as a secondary potentially enhance vascularity and wound healing potential procedure at a later date. Split‑thickness skin grafting was during the period of demarcation of necrotic tissue. the method of choice when adequate soft tissue padding Hyperbaric oxygen therapy utilizes 100% oxygen at was present. In the authors’ experience, the risk of calcaneal pressures greater than atmospheric pressure. In the bone exposure was decreased in patients treated with HBO current study, HBO was administered in a Monoplace therapy. Split thickness grafting can suffice if adequate soft chamber in which a single patient is placed in a chamber tissue padding is present.[2] However, there is a need for a that is then pressurized with 100% oxygen. The pressure randomized controlled study of the preservation of heel inside the chamber is adjusted, ranging from 2.0 ATA to fat pad tissue following HBO therapy. Out of 7 cases of 2.4 ATA for duration of 90 min. As an adjunct to surgery complete avulsion, 1 patient was managed by full‑thickness and antibiotics, HBO therapy can significantly decrease skin grafting. The benefit of HBO therapy is greatest in costs and complications.[8] Vasoconstriction reduces edema cases in which relatively large areas of tissue are grafted, and tissue swelling while ensuring adequate oxygen as in full‑thickness skin grafting.[8] One patient with a heel delivery and is thus useful in acute trauma wounds. pad defect was treated by reverse sural artery flap coverage, Hyperoxygenation of the crush injury and compartment and four patients were managed by free tissue transfer. syndrome followed by flap salvage results in immune Among the free tissue transfer cases, 2 were latissimus stimulation by restoring white blood cell function and dorsi muscle flaps, 1 was a gracilis muscle flap and one was enhancing phagocytic capabilities. Neo‑vascularization in an anterolateral thigh flap. There were no complications hypoxic areas is augmented by fibroblastic activity and following any flap transfers. The patients in the current capillary growth.[8] Adequate shock management, direct series did not experience the common side effects of HBO surgical intervention with debridement, repair of soft therapy, including aural or pulmonary barotrauma and tissues and any damaged vessels, and stabilization of transient reversible myopia during the treatment session. bony elements are of paramount importance. Adjuvant No recent literature is available on management of heel HBO can be given early to prevent large regions of pad avulsion injuries using surgery and HBO therapy ischemic necrosis, minimize the frequency and extent of as a combined modality. Other advanced wound care

60 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 modalities including negative pressure wound therapy and environment which requires surgical intervention. Measures limited‑access dressings could well be utilized along with that could improve the outcome with the adjunct use of HBO therapy for the management of such challenging HBO therapy should be considered [Figure 7]. injuries. Complications and problems in wound healing are In conclusion, the goal of management of heel pad bound to occur in crush injuries of the foot involving heel avulsion injuries is to preserve as much viable heel pad pad region. HBO therapy is an adjunct in the management tissue as possible and to provide sensate, stable coverage. of marginal tissues, but cannot be utilized in an avascular Principles of wound management with wound evaluation,

Figure 6: Algorithm for management for heel pad avulsion injuries in our institution

Figure 7: Hyperbaric oxygen therapy as an adjunct in the management of various patterns of heel pad avulsion injuries

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 61 debridement with preservation of viable tissue, fracture Results of infrapopliteal endovascular procedures performed in diabetic reduction, prevention of infection, and adequate soft tissue patients with critical limb ischemia and tissue loss from the perspective of an angiosome‑oriented revascularization strategy. Int J Vasc Med reconstruction are important in the management of heel 2014;2014:270539. pad avulsion injuries. The simplest and most appropriate 5. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot technique is likely to produce the best outcome. This and ankle and clinical implications for limb salvage: reconstruction, incisions, study presents a simple management algorithm for and revascularization. Plast Reconstr Surg 2006;117:S261-93. 6. Latham E, Hare MA, Neumeister M. Hyperbaric oxygen therapy. eMedicine. the management of various types of heel pad avulsion In: Schraga ED, Windle ML, Scudder L, editors. Medscape. Available from: injuries. HBO therapy may be used as a useful adjunct in http://www.emedicine.com/plastic/topic526.htm. [Last accessed on Aug 2014]. the treatment of such complicated injuries to offer speedy 7. Ulkür E, Karagoz H, Ergun O, Celikoz B, Yildiz S, Yildirim S. The effect recovery as well as cost benefits. of hyperbaric oxygen therapy on the delay procedure. Plast Reconstr Surg 2007;119:86‑94. 8. Bhutani S, Vishwanath G. Hyperbaric oxygen and wound healing. Indian J REFERENCES Plast Surg 2012;45:316‑24. 9. Kemmer A. Crush injury and other traumatic ischemia. In: Mathieu D, editor. 1. Mohammed R, Metikala S. Anchorage of partial avulsion of the heel pad with Handbook on Hyperbaric Medicine. Netherlands: Springer; 2006. p. 311‑2. use of multiple kirschner wires. A report of four cases. JBJS Case Connect 2012;2:20. 2. Suri MP, Patel AG, Vora HJ, Raibagkar SC, Mehta DR, Vyas UH. Post‑traumatic How to cite this article: Mukundan PK, Ambookan PV. Heel pad posterior heel soft tissue defect reconstruction. Indian J Plast Surg avulsion injury: an approach with hyperbaric oxygen therapy. Plast 2005;38:138‑43. Aesthet Res 2015;2:56-62. 3. Levin LS. Foot and ankle soft‑tissue deficiencies: who needs a flap? Am J Source of Support: Nil, Conflict of Interest: None declared. Orthop (Belle Mead NJ) 2006;35:11‑9. 4. Acín F, Varela C, López de Maturana I, de Haro J, Bleda S, Rodriguez‑Padilla J. Received: 19-08-2014; Accepted: 28-09-2014

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